Wednesday, August 29, 2012

Is brain death - death? New Canadian brain-death guidelines.

This article that was written by Tom Blackwell and published in the National Post asks the question whether or not organ donors are actually dead before their organs are removed? The new Canadian guidelines for brain death are designed to increase the number of available organs for transplant. Some experts say they make it less likely that the donor is actually dead.

There have been many concerns about whether organ donors are dead before their organs are removed. The Canadian guidelines appear to make it more likely that death will occur from the removal of organs rather than waiting for death to occur and then removing organs.Alex Schadenberg

Months into the latest national campaign to recruit desperately needed organ
donors, a legal scholar is arguing that new guidelines for declaring people
brain dead and eligible for organ harvesting likely violate the Charter of
Rights and Freedoms.

The non-binding rules developed by a government-appointed expert panel in
2004 — designed to expand the pool of transplant donors — make it more likely
that people are being declared dead when they are still alive, and were drafted
with no public input, complains Jacqueline Shaw in the McGill Journal of Law and
Health.

Given that the panel’s “inappropriately one-sided” guidelines emerged from a
government transplant initiative, they are subject to the Charter, and appear to
violate the right to life, liberty and security of the person, she argues.“The recent government issuance of significant, dangerous, under-the-radar
changes in guidelines for brain death determination in Canada is virtually
unknown and warrants greater public attention,” she said in an email exchange
with the National Post. “The brain-death changes dramatically increase
the potential to misdiagnose as ‘brain dead’ patients who are simply suffering
from temporary, reversible neurological states.”

A spokesman for the country’s largest transplant organization dismissed the
lengthy analysis, though, saying the rules are “highly respected worldwide” and
designed to make the process of determining brain death consistent and rigorous,
not faster or easier.

“More often than not, it delays the declaration of death, so the physician at
the bedside gets it right,” said Dr. Sonny Dhanani, a pediatric critical-care
specialist in Ottawa and chief medical officer with Ontario’s Trillium
transplant network. “At the end of the day, the goal … was to make declaration
more consistent and rigorous so that we felt better about moving toward organ
donation, rather than uneasy about it.”

Dr. Sam Shemi, a prominent Montreal intensive-care physician who headed the
panel Ms. Shaw criticizes, told the National Post last year that
current practice leaves no doubt that donors are dead, with a process that is
“performed according to a higher standard than in any other [medical]
situation.”

Underlying the debate are some stark statistics — the chronic shortage of
donor organs means about 300 sick Canadians die every year on the waiting
list.

Still, the journal article adds to a simmering controversy around declaring
when critically ill patients are dead. While most in the medical community seem
to accept the validity of the Canadian Council for Donation and Transplantation
(CCDT) guidelines issued in 2004, a small but persistent minority of
intensive-care physicians, bio-ethicists and others in Canada and the United
States continue to argue that some donors may still be alive, at least
technically.

A 2010 journal paper by Canadian and U.S. doctors called for a moratorium on
the relatively new practice of declaring death after the heart has stopped, but
without determining brain death. Another paper, co-authored by a Toronto
intensive-care physician, suggested last year that the dead-donor rule be
abandoned and replaced with what the doctors called a more transparent approach:
telling families that their loved one is ultimately doomed, but may not be
completely dead at the time the organs are removed.

The CCDT was set up by federal and provincial governments as concern grew in
the 1990s about the continuing shortage of organs for transplant. The rules it
drafted have been adopted by many jurisdictions across the
country.

The article singled out a number of changes that Ms. Shaw said increase the
potential for mistakes by making it possible to declare brain death earlier and
more simply.

One was that brain death could be declared when the brain stem is no longer
functioning, altering the previous “whole brain” rule that required doctors to
determine that the cortex had also shut down, the article said. Ms. Shaw argues
there could still be some consciousness in the cortex even after the stem has
died.But Dr. Dhanani said that when the brain stem — the most primitive part of
the organ that controls basic functions like breathing — no longer works, it
follows that the entire brain must be dead.

The article also suggested that the guidelines’ abandoned “time-honoured”
safeguards, such as not declaring brain death until anticonvulsants, sedatives
or other drugs that can bring about a death-like state have drained completely
from the system. Dr. Dhanani said the rules still require care to ensure such
medicines are not affecting the patient’s condition, but said there is really no
way to determine they are completely gone from someone’s body.

The 2004 rules say the separate brain-death tests that must be carried out by
two different doctors can be performed simultaneously. The previous guidelines
called for a wait time of up to 24 hours in between examinations, which Ms. Shaw
said allowed for the slim possibility the person could be deemed alive at the
second test. There is no evidence, though, that the lag-time ever made any
difference, said Dr. Dhanani.

Ms. Shaw argued the CCDT’s recommendations “dramatically redefined” how death
is determined, but said the broad public was never consulted in advance, or
notified of the changes after the fact.Previous articles on the same topic: